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Transfusion Guidelines Updated February, 2005

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Transfusion Guidelines Updated February, 2005 Transfusion Guidelines Updated February, 2005 I. Whole Blood The use of whole blood is not recommended and is not available from the Blood Center. Blood components should be selected according to the patient’s needs. II. Red Blood Cells (RBCs) Transfusion must be completed within 4 hours of issue from the Blood Bank. If transfusion is not begun immediately the RBCs must be stored at 1-6° C or returned to the Blood Bank. (Storage is only allowed in preapproved areas, such as the operating room and several of the critical care areas). The effectiveness of each transfusion should be documented in the medical record. Single unit transfusions of RBCs are often effective. In adult patients, one unit of RBCs will increase the hemoglobin level by approximately 1 g/dl (hematocrit by 3%). A. Acceptable Usage 1. Acute Blood loss exceeding 30-40% of blood volume (pediatric patients - 10-15 ml/Kg) and/or not responding to appropriate volume resuscitation, and/or with ongoing blood loss. 2. Patient is normovolemic and there is evidence to support a need for increased oxygen carrying capacity by the following : a. Hypotension not corrected by adequate volume replacement alone. b. PVO2<25 torr, when SaO2 completely saturated; extraction ratio>50%, VO2<50% of baseline. c. Neonates and young infants less than 56 weeks postmenstrual age with hematocrit < 0.30 and frequent and/or severe apnea/bradycardia, poor weight gain, sustained tachycardia and/or tachypnea or mild respiratory distress. d. Neonates and young infants less than 56 weeks postmenstrual age with hematocrit < 0.35 and moderate respiratory distress or with hematocrit < 0.40 and severe respiratory distress, cyanotic congenital heart disease or receiving extracorporeal membrane oxygenation. 3. Hemoglobin of ≤ 7 gm/dl (hematocrit ≤ 21%), if not due to a treatable cause. Treatment of underlying cause is preferable if patient is not symptomatic. 4. Preoperatively for patients with a hemoglobin ≤ 8 gm/dl (hematocrit ≤ 24%) with the potential for significant blood loss. 5. Hemoglobin < 9 gm/dl (hematocrit < 27%) in a patient with coronary artery disease (unstable angina/ myocardial infarction), cardiogenic shock or congestive heart failure. B. Not recommended 1. For volume replacement alone. 2. In place of a hematinic. 3. For enhancement of wound healing. 4. To improve general “well-being”. Clarian Transfusion Guidelines III. Washed RBCs: A. Acceptable Usage 1. History of anaphylactic reaction to blood components. 2. History of prior severe allergic transfusion reactions not prevented by pretransfusion administration of antihistamines. 3. IgA deficiency with documented IgA antibodies. 4. Febrile reactions associated with red cell administration not prevented by leukocyte reduction. 5. Extracorporeal membrane oxygenation, exchange transfusion or large volume transfusion (> 20 mL/kg) in pediatric or neonatal patients. B. Not recommended for leukocyte reduction to prevent febrile reactions. IV. Leukoreduced RBCs A. Acceptable Usage 1. Prevention of HLA/WBC alloimmunization. 2. Prevention of nonhemolytic febrile reactions. 3. Prevention of CMV transmission in immunosuppressed patients. 4. Neonates and young infants less than or equal to 56 weeks postmenstrual age. 5. Intrauterine transfusion. B. Possible Benefits of Leukoreduction 1. Reduced post-operative infections. 2. Reduced cardiac surgery mortality. 3. Reduced transfusion-induced immunomodulation. 4. Prevent post cardiopulmonary bypass lung injury. C. Physicians may request leukocyte-reduced RBCs for a patient or patient group not listed above. V. Platelets (plateletpheresis or platelet concentrates): Transfusion should begin immediately upon receiving platelets. Once initiated, transfusion must be completed within 4 hours. A single adult dose of platelets (one apheresis or 5 concentrates) should increase the platelet count by 25-35,000/µl. A second dose may be indicated if there was an inadequate post-transfusion increment (CCI) and/or continued microvascular bleeding. Each dose of platelets contains the equivalent of one unit of plasma (plasma in platelet concentrates has decreased levels of factors V and VIII). A. Acceptable Usage 1. Prophylactically in a nonbleeding patient with failure of platelet production and platelet count ≤ 10,000/µl (< 30,000/µl in term neonates and < 50,000/µl in preterm neonates). 2/15/2005 2 Clarian Transfusion Guidelines Platelets, Acceptable Usage, con’t. 2. Patient with platelet count < 20,000/µl (< 50,000/µl in neonates) and signs of hemorrhagic diathesis, as manifested by petechiae and/or mucosal bleeding. 3. Normothermic patients with signs of diffuse microvascular bleeding . 4. Patient to undergo surgery or invasive procedure where clinically significant bleeding is anticipated and platelet count ≤ 50,000/µl (See Notes below). 5. Diffuse microvascular bleeding following cardiopulmonary bypass or with intra-aortic balloon pump and platelet count not yet available or < 100,000/µl. 6. Bleeding in a normothermic patient with documented qualitative platelet defect, regardless of platelet count. 7. Massive transfusion (> 1 blood volume) with diffuse microvascular bleeding and inadequate time to obtain platelet count. Correct hypothermia. (See Notes below). 8. Extracorporeal membrane oxygenation with platelet count < 100,000/µl. B. Notes 1. Massive transfusion - Platelet transfusions are not required unless there is evidence of diffuse microvascular bleeding and /or platelet count ≤ 50,000/µl. Prophylactic platelet transfusions are not necessary. Correct the hypothermia. 2. Idiopathic immune thrombocytopenic purpura - Platelet transfusions are not indicated unless there is life-threatening bleeding. (During splenectomy, platelet transfusions may be used if necessary after clamping the splenic vascular pedicle.) 3. Thrombotic Thrombocytopenic Purpura/Hemolytic-Uremic Syndrome - Platelet transfusions are a relative contraindication and may worsen the patient’s condition. 4. Systemic hypothermia (< 35° C) - The associated thrombocytopathy is best treated by warming the patient. 5. The majority of platelet products supplied by the Blood Center are plateletpheresis products that are leukoreduced. VI. HLA-Matched or Crossmatched Platelets A. Acceptable Usage 1. Patients who are immunologically refractory to platelets, i.e. no clinical cause(s) for their refractory state. VII. Fresh Frozen Plasma (FFP): For an adult patient, a maximum of 4 units of FFP will be thawed at one time. Transfusion of FFP must be completed within 4 hours of issue from Blood Bank. A. Acceptable Usage 1. Treatment of a clinical coagulopathy due to deficiency of procoagulants other than Factor VIII, IX, or fibrinogen as indicated by the following: a. Actively bleeding patient or patient scheduled for surgery or invasive procedure with PT and/or PTT > 1.5 times the mean of the reference range (10-15 ml/kg will usually suffice). b. Prophylactically in critically ill patients with a clinical coagulopathy at risk for 2/15/2005 3 Clarian Transfusion Guidelines further bleeding. FFP, Acceptable Usage, con’t. 2. Coumadin effect/overdose with major injury/bleeding or impending surgery if vitamin K cannot be used; vitamin K reversal usually occurs within 12-24 hours. Trauma patients on Coumadin need immediate reversal using both FFP and vitamin K. 3. Treatment of documented or presumptive Antithrombin III deficiency and concentrate is not available. 4. Treatment of thrombotic thrombocytopenia purpura or hemolyticuremic syndrome. B. Not recommended: 1. For volume expansion. 2. For treatment of nutritional deficiencies. 3. Prophylactically with massive transfusion - FFP should be used only if there is documented laboratory or clinical evidence of diffuse microvascular bleeding. Most microvascular bleeding associated with massive transfusion is due to thrombocytopenia and is best treated with platelet transfusions which also contain large amounts of plasma (250 ml/5 units of platelet concentrate; 250-300ml/ plateletpheresis). VIII. Cryoprecipitate One unit of cryoprecipitate per 10 kilograms body weight should be adequate to achieve hemostasis. An average adult dose should therefore be 6-8 units, with 10 units as a maximum single dose (unless the patient is receiving fibrinolytics and/or fibrinogen < 50 mg/dl, in which case 20 or more units may be necessary). A. Acceptable Usage 1. Documented hypofibrinogenemia. a. Actively bleeding patient with fibrinogen ≤ 100 mg/dl. b. Prophylactically in patients in whom a bleed may cause serious clinical sequelae and fibrinogen ≤ 100 mg/dl. c. Fibrinogen < 125 mg/dl associated with diffuse microvascular bleeding. 2. Dysfibrinogenemia. 3. Von Willebrand’s disease not treatable with DDAVP and von Willebrand concentrate (intermediate purity factor VIII concentrates such as Humate P or Alphanate) unavailable. 4. Select cases of hemophilia A unresponsive to DDAVP when factor VIII concentrates are unavailable. 5. Factor XIII deficiency. 6. Fibrin glue. 7. Uremic bleeding unresponsive to DDAVP. 2/15/2005 4 Clarian Transfusion Guidelines IX. Factor VIIa concentrate (NovoSeven) A. Acceptable Usage 1. Factor VIII and IX deficiency with inhibitor levels greater than 5 Bethesda units. B. Off-Label Use 1. Off- label uses include enhancement of primary and secondary hemostasis (other than factor VIII and IX inhibitors). Factor VIIa is the treatment of choice for patients with factor VII deficiency and significant hemorrhage. 2. Off- label use should be approved (see Clarian guidelines). X. Factor VIII concentrate A. Acceptable
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